Medical mystery: An unusual case of congestive heart failure

An elderly woman came into my office recently because of shortness of breath. She also noted that her legs were swollen through much of the day.

She told me she was taking medication and had been for years because of her long history of hypertension.

I ordered a chest X-ray, which showed mild congestive heart failure (CHF).

CHF is a scary diagnosis, resulting in more hospitalizations than all kinds of cancer combined. In the United States, five million people are affected, with 550,000 new cases every year.

I ordered an echocardiogram, or ultrasound, of her heart. This showed thickening of the walls of her heart muscle, but normal squeezing of the heart (also known as ejection fraction).

She was started on furosemide (Lasix) to help her leg swelling and CHF, but she did not feel better.

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When someone is breathless and it is heart related, it is often because of CHF. If the heart does not squeeze properly, it operates less efficiently, and fluid can back up into the lungs. This may result in a sensation of drowning. The medical term is heart failure with reduced ejection fraction. It is treatable with medications and diagnosed by history, exam, a chest X-ray, blood tests, and an echocardiogram. But my patient did not have this, as her ejection fraction was normal.

What was causing her symptoms?

There are two different types of CHF, which are treated differently.

The woman I saw that day had the less understood kind of heart failure, called diastolic failure. The medical term for this is heart failure with preserved ejection fraction. This occurs when the heart does not properly relax, but still squeezes normally.

For decades, cardiologists had few medications other than diuretics (water pills) to treat this form of CHF. This year, for the first time, there are new medications that can help.

It actually is not a heart medication, but one used to control diabetes. Empagliflozin (Jardiance) has been shown to be more effective than any heart medications for this condition. This medication reduced the risk of cardiac death or hospitalization for heart failure regardless of whether patients had diabetes. In the EMPEROR-Preserved trial, published in the New England Journal of Medicine and financed by the drug manufacturer that makes Jardiance, almost 6,000 participants with diastolic failure took either the drug or a placebo. Researchers found there was a 21% lower risk of hospitalization or cardiac death when patients took Jardiance.

One major proviso: Jardiance is so expensive that many patients can’t afford it.

Jardiance costs $582 a month without insurance. Another medication, called dapagliflozin (Farxiga), has a trial still in progress that is expected to show similar results. It’s a close cousin to Jardiance, and is just as expensive.

One of the trial investigators recommended that both empagliflozin (Jardiance) and sacubitril/valsartan (Entresto) at $618 per month be taken together for his patients with heart failure. But this treatment plan is not realistic without the best insurance.

These are signs of a two-tiered system where different (and better) medications are developed and prescribed only to those who are lucky and wealthy enough to have good insurance.

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As a cardiologist, I find it strange to be prescribing an expensive medication for diabetes to help treat heart failure. I have not yet done this, leaving such prescriptions to be written by diabetes experts (endocrinologists) and family doctors. The truth now is that this drug is indicated for both kinds of heart failure and should officially be considered a cardiac medication.

If my patient with shortness of breath can afford it, I will prescribe it for her. It is not a conversation I am looking forward to, as we may be discussing beginning something she cannot afford. She is of Medicare age, so I doubt her insurance will cover it. The only other effective medications available for this kind of heart failure are diuretics and equally expensive Entresto, which a new study suggests are not as good. I am glad this medication is available to treat a previously undertreated condition, but really wish it was less pricey.

David Becker is a board-certified cardiologist with Chestnut Hill Temple Cardiology in Flourtown. He has been in practice for more than 25 years.